Paternalism and expertism

I very much enjoyed the responses to my last post. I’d hoped to engender a vigorous discussion, and it worked. Now we need to expand on the conversation.

We’ve had many discussions on this blog over the years about the conflict in medicine between autonomy and paternalism, that is how much value to place on the choices and freedom of the patient vs. the expertise and advice of the doctor. In the past, medicine relied heavily on paternalism, with doctors dispensing “orders” to patients without needing to answer many questions. In fact, it seems as if paternalism was at its peak when doctors had fewer answers. Over the years both medicine and our culture has changed, with much more being known about medicine, and oddly, more patient participation being both needed and desired.

Do I get a colonoscopy for an eighty year-old patient? I can’t really know without my expertise of cancer screening combined with a knowledge of my patient’s values. What came up in my last post though was both questions: what if a doctor is too paternalistic to know my values, and what if my doctor doesn’t have sufficient expertise?

A certain dose of paternalism is necessary in medicine, and a patient shouldn’t go to a doctor expecting to have to answer all their own questions. I trained for so many years so that I can help patients find the knowledge they need to stay healthy, regain health, or leave the world as painlessly as possible. People who “doctor shop” until they find someone willing to do what no other doctor will (e.g. some fancy, unproven heart test or some bioidentical hormone nonsense) probably misunderstand what expertise is. I have a great deal of respect for people who doctor shop looking for someone with knowledge and compassion; doctors who are willing to listen to and answer difficult questions, and dispense difficult answers. But ultimately there is a level of trust that has to precipitate. The doctor has to trust that the patient is doing their best to give them information, and the patient must trust the doctor to have the proper expertise and to dispense good advice.

There is no one way to confirm a primary care doctor’s expertise. It helps to see if they are board-certified in their specialty (primary care usually includes internal medicine, pediatrics,and family medicine). It also helps to have heard good things about them in the community. But ultimately you have to figure out if you trust them, if they give advice backed up by data when you ask for it, if they give choices (even if a choice is “take this pill or risk a heart attack”), and if they are willing to say things you don’t want to hear.

Every primary care doc has a different pattern of using sub-specialists, depending on their comfort dealing with various problems and the resources at their disposal. I’m fortunate to have been well-trained and to have a lot of resources at my disposal. I’m also not involved in many insurance plans that penalize me for referring. My tendency is to do as much as I can on my own for problems that are within my expertise, and to refer when I’m over my head or a problem is obviously not “mine” (e.g.,I’m not a surgeon, and your appendix is not coming out in my office).

But others may feel less comfortable and may wish to refer earlier. Or they may wish to but face incentives from HMOs not to. It’s a mess out there, and adding in patient preference makes it messier, but it’s necessary. A good doctor knows when to refer and knows when to help guide a patient’s choice. If a patient has lost their trust in me to treat their blood pressure—one of my basic jobs—they probably shouldn’t be seeing me at all. If, on the other hand, I’ve run out of ideas about their blood pressure and want to ask for help, I hope they see this as a strength rather than a weakness.

Patients are in a real bind. They don’t know if a doctor is in over their head, and they don’t know what incentives a doctor may be facing—but they can ask, frankly and often (hopefully asked respectfully, for the sake of the relationship). While insurance and geography may limit choice, there is still often some measure of choice, and doctor’s who aren’t willing to answer questions about their own expertise are either a bit too touchy or more worried than they’ve let on.

7 Comments

stumbled on this blog and felt that a small comment was called for from my end of things. I’m a Swedish academic, specializing in applied ethics, especially in the health care field. When you write that a certain dose of paternalism is necessary when practicing as a physician this strikes me as odd, since what you then go on to describe is simply that if you are going to practice medicine in a good way you need to do it out of some extent of care for your patients. Perhaps that is called paternalistic in the USA, my reaction thus being due mainly to cultural/linguistic differences. But as the term is mostly used among ethicists internationally, paternalism is not simply acting towards another person out of care for her, but to do that by subjecting her to force, threat or manipulation. In other words, not offering whatever a patient may be asking for due to reasons of safety or efficacy or wise allocation of health care resources is not paternalistic at all. It is simply being a responsible professional. As you say, the patient may respond by trying to get what he’s after from someone else if you are not successful in presenting your case in a way that makes the patient trust you. But, again, there is nothing forceful or manipulative about that, although perhaps something that a doctor have reason to take note of and learn from. Even less is telling the patient your professional opinion in the best way you can paternalistic – even if that entails an element of persuasion. Paternalism would rather be if you withheld that opinion or presented it less clearly that you are able to for fear of, e.g., worrying or frustrating the patient – that would be manipulating him for his own good.

What is often argued in the US context is that anything other than giving a patient a menu of choices is paternalism. There is a strong bias among some americans against the role of the expert, democratizing that term into non-existence.

Melissa T.

Christian – it is perplexing to hear about an acceptable level of paternalism in medicine. However, I had one friend, who is an MD and also a father explain it to me this way.

He has a son who has a rare illness but it is not life threatening. It was diagnosed very early on and in infancy. As he was speaking with his son’s pediatrician he was asking very high level questions about this particular illness when suddenly the doctor looked at him and INSTEAD of answering them colleague to colleague and medical jargon with return medical jargon he said, “Your son is going to have a normal life. He will grow up and play and run around and be happy.”

My friend continued to press for MORE information – he wanted to know about this illness beyond the treatment. Again the pediatrician said, “He will probably play football if he grows up around here even though you were a baseball player.”

My friend was VERY angry and insulted. He felt talked down to for weeks. And then a month or two later he realized something. He had a normal child with an illness. Not an illness with a child. He got it. He realized that he had received a bit of “paternalism” in that the pediatrician had decided to treat him like a “typical parent” instead of another doctor. And now he has a normal healthy son who happens to have a rare illness but his son is happy and preposterous and silly and makes a giant mess when we go out to eat. And no one treats his son like a little walking illness. And THAT is a big point and it is a difficult message to send and this pediatrician kept ignoring the question and putting the emphasis on the CHILD because the illness was being HANDLED. (Obviously, later the questions all got answered – but at the time- it was more important to focus on the child and not on creating an identity of illness for the family).

This was how my friend described how another doctor used benign paternalism on him and how he realized it was something positive at the time. A doctor with experience knows the right touch. It helped me understand it.

Old Geezer

The most important word you used up there is “trust.” If I, as a patient, come to you already knowing that you are just BSing me, that all you want to do is control me, or that you are part of a great conspiracy involving unneeded surgery, then the necessary trust cannot exist.

I believe I know more than the average citizen about anatomy, physiology and pathophysiology. I’m absolutely sure that my doctor knows a lot more about those subjects than I ever will. If I cannot trust him, I will have to find whom I can trust. If I can trust him, then I am happy to discuss my opinions and my options. That makes us a team. But every team has to have a manager and I bow to the expert when it comes time to define what my disease is and will seek that manager’s advice without negative characterization.

A little over 200 years ago, the practice of medicine was absolutely barbaric which laid a perfect groundwork for homeopathy (stay with me here) because in many cases, doing absolutely nothing (aka, administering homeopathic treatments) was still preferable to doing what everyone else wanted to do to you. Homeopathy (doing nothing) actually is better than actively harming the patient, but it’s still not the ideal route. Ultimately, medicine improved and those who argued so vehemently that your odds of survival were improved if you chose homeopathy over (then) traditional medicine, were soon the ones that held the antiquated view. Why? Because both the process of doing medicine and the doctors themselves improved.

I think there’s a certain parallel to medicine now. Before patients had readily available access to medical information, written in layman’s terms, you had two choices; trust what your doctor said implicitly or study medicine (ok, in truth, you could also seek out a second opinion, but I think you get my point). It is better that patients can inform themselves, advocate for their own best interests and make themselves experts on something that is meaningful to them but might be only 1 of thousands of issues a primary care physician has to know about to manage her practice.

The downside to this is that patients overcompensate, homeopathy style, presuming that paternalism and profit motives drive doctors when a patient doesn’t agree with the recommended course of action. We see this in people’s choices to forego vaccines for their children, birth at home, choose chiropractic or load themselves up with herbal remedies in lieu of real treatment for disorders. This is a natural, albeit unfortunate offshoot of patients feeling empowered in their own medical choices.

At some point, there will need to be some balance. For my own part, I’ve moved a lot over the past 10 years and therefore had a lot of doctors. I may have simply chosen well (and have been fortunate enough to be able to choose a PPO over HMO), but I’ve found that all of my doctors in the past 5+ years have encouraged me to do my own research and then have asked me to weigh in on my thoughts, concerns and misgivings. That is to say, I see doctors actively walking to the middle ground, to do their part to adapt to this new-ish manner of dealing with their patients. What I think is going to take longer is for patients to do the same. I’m not sure when that will happen. We currently live in a nation where half the population would rather choose a president by who they’d prefer to have a beer with instead of who seems most qualified, but ultimately, just as almost all of us have to rely on the expertise of a mechanic, electrician, carpenter or other professional, to make the right choices in areas we lack experience and education, so must we concede that the internet doesn’t confer a medical degree no matter how many hours we spend online and that we need an expert to guide our choices in medicine too.

Karen

I’ve had a decidedly mixed experience with doctors in the last few years, and I’m grateful that I’ve acquired, over the course of my life, an ability to ask important questions and not just accept meekly what I’m told. I have an unexplained dry cough, that acts up especially during exercise, and severely limits my workouts. I’m also obese, and not being able to exercise without coughing myself lightheaded doesn’t help. My allergist has torn her hair out trying to treat it; it doesn’t help that it’s partially tied in with asthma and allergies. Inhalers and such only help so much. CT scans reveal that my lungs are healthy. I trust the allergist (and the pulmonologist who reviewed the CT scans.)

Then there’s the gastroenterologist who might have tested me for reflux; but he basically declared that all allergists were idiots, if I didn’t have heartburn I couldn’t possibly have reflux, and to go away and lose some weight. After that speech, I honestly couldn’t think of any questions to ask (at least not that would have been polite).

I’m trying to lose weight, but it’s hard. I still have the cough. I take Prevacid (prescribed by the allergist) and struggle. It’s so fracking hard.